A nurse in the emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first?
A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F)
A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10
A client who has left shoulder pain and S-T elevation on a 12-lead ECG
A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities
The Correct Answer is C
A. While a temperature elevation in a client with Clostridium difficile requires assessment, it is not as urgent as potential cardiac ischemia.
B. Pain assessment in a client with a femur fracture is important but does not take priority over potential cardiac issues.
C. Left shoulder pain with S-T elevation on an ECG can indicate myocardial infarction (MI), a life-threatening condition requiring immediate assessment and intervention.
D. Orthostatic hypotension and pitting edema, while concerning, do not indicate an acute, life-threatening condition that requires immediate assessment in this scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While completing an incident report is important for addressing the medication error and implementing corrective actions, the immediate priority is to assess the client's condition for signs of bleeding, which could be life-threatening.
B. Monitoring aPTT levels is important to assess the client's response to heparin therapy, but it does not address the immediate risk of bleeding from the overdose.
C. Notifying the risk manager is essential for reporting the medication error and implementing strategies to prevent future occurrences, but the nurse's first action should be to assess the client's condition for any indications of bleeding.
D. Administering a high dose of heparin increases the risk of bleeding, so the nurse should first assess the client for any signs or symptoms of bleeding, such as unexplained bruising, hematuria, or hypotension, to ensure timely intervention and prevent complication.
Correct Answer is A
Explanation
A. Raised facial rash, often in a "butterfly" distribution across the cheeks and bridge of the nose, is a characteristic manifestation of systemic lupus erythematosus.
B. Hemangiomas are not typically associated with systemic lupus erythematosus.
C. Kaposi's sarcoma lesions are associated with immunosuppression, such as in HIV infection, and are not a typical finding in systemic lupus erythematosus.
D. Psoriasis is a separate autoimmune condition characterized by red, scaly patches on the skin and is not typically associated with systemic lupus erythematosus.
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